Facilitators in treatment pathways for depression or anxiety among adults in Nepal: A qualitative study

Background: Depression and anxiety are prevalent mental health issues globally, yet many individuals in low- and middle-income countries lack access to treatment. Limited research exists on mental health service utilization in these regions. Understanding the factors that impact access to care and treatment pathways can enhance mental health services. This study investigates the factors that support the initiation and continuation of treatment for depression or anxiety in Nepal. Methods: The study was conducted in Jhapa, Chitwan, and Kailali districts in Nepal, representing the eastern, central, and far-western regions. The participants were adults receiving treatment for depression or anxiety from a range of healthcare providers. A total of 24 participants were purposively recruited, including 13 with symptoms of depression, 9 with symptoms of anxiety, and 2 with both conditions. We utilized the McGill Illness Narrative Interview, a semi-structured protocol commonly used in mental health research, to gather detailed narratives on symptom experiences, illness accounts, and help-seeking behaviors. Data analysis was performed using a framework and thematic analysis approach with NVIVO software. Results: Treatment pathways for depression and anxiety in Nepal were found to be complex, involving multiple service providers and recurrent treatment from the same providers. Out of a total of 137 sessions across 24 patients, the majority of sessions were with traditional faith healers (27.7%), followed by private hospitals (19.7%), primary healthcare facilities (16.1%), government hospitals (13.1%), neighboring countries (8.0%), and private clinics (11.7%). Traditional healers were the most popular places for initial visits, followed by private clinics and government hospitals. Factors such as service quality, providers behavior, availability of trained providers, appointment process, confidentiality, and types of services offered influenced care-seeking decisions. Support from family or friends, awareness of mental health issues, and recommendations from trusted individuals also played a significant role. Conclusion: Treatment pathways for depression and anxiety disorders are complex, often involving multiple sessions with different service providers and a combination of services. Improving healthcare providers' behavior, appointment scheduling, and consultation quality is essential to encourage individuals to seek care. Raising awareness about mental health conditions and available services through various channels as well as training traditional healers in mental health could enhance access to care.